From the Brontës to J.K. Rowling and Beyond – Have We Hit a Wall? The Status of Women Authors

Abstract

Gender disparities in writing are not unique to medicine. Over the centuries, many renowned female authors of all genres devised clever ways to get their works published. The reason for this is obvious – to overcome publisher bias and to reach a broader audience that included men who might otherwise consider female-penned works inferior. The list of such accomplished women is long – the Brontë sisters, Charlotte, Emily and Anne adopted the male pseudonyms Currer, Ellis, and Acton Bell; Mary Ann Evans published under the famous name of George Eliot; Nelle Harper Lee went by the more ambiguous Harper Lee. Some might still mistakenly believe that this strategy was a historical phenomenon born out of necessity and is no longer relevant in modern day society–think again. On the advice of her publisher, Joanne K. Rowling, one of today's most successful authors, used her initials instead of her first name to conceal her gender from the Harry Potter audience, a fact that might otherwise have discouraged boys and men from reading her works. And so it goes… So why all this talk of women and literature over the centuries? The answer is simple—whether we are discussing great literary works, science and technology, or medicine women have faced hurdles to get published. The reasons for this are complex and beyond the scope of an editorial, however, the statistics can neither be dismissed nor simply attributed to personal choice. Jagsi et al brought attention to this phenomenon in their 2006 study on the gender gap in authorship in 6 prominent medical journals over 35 years.1Jagsi R. Guancial E.A. Worobey C.C. et al.The “gender gap” in authorship of academic medical literature—A 35-year perspective.N Engl J Med. 2006; 355: 281-287Crossref PubMed Scopus (607) Google Scholar Since this landmark publication, the subject of gender-related bias in the medical literature has gained significant traction, with multiple reports addressing gender disparity in number of publications, grants and scholarships, time to academic promotion, hospital leadership positions, access to mentors, and other career resources.2Blumenthal D.M. Olenski A.R. Yeh R.W. et al.Sex differences in faculty rank among academic cardiologists in the United States.Circulation. 2017; 135: 506-517Crossref PubMed Scopus (86) Google Scholar, 3Thibault G.E. Women in academic medicine.Acad Med. 2016; 91: 1045-1046Crossref PubMed Scopus (42) Google Scholar, 4Rochon P.A. Davidoff F. Levinson W. Women in academic medicine leadership: Has anything changed in 25 years?.Acad Med. 2016; 91: 1053-1056Crossref PubMed Scopus (97) Google Scholar Although there are no clear and distinct barriers that impede a woman's professional growth in academia, she may not have equal access to important assets, including networking and mentorship. A key requirement for academic advancement is lead involvement in research and publications in high-impact peer-reviewed journals. In this issue of the Journal, Pagel et al have examined gender-based differences in authorship of manuscripts from the U.S. that were published between 1990-2017 in the Journal of Cardiothoracic and Vascular Anesthesia.5Pagel PS, Freed JK, Lien CA. Gender differences in authorship in the Journal of Cardiothoracic and Vascular Anesthesia: A 28-year analysis of publications originating from the United States, 1990-2017. J Cardiothorac Vasc Anesth (current issue).Google Scholar They included in their analysis peer-reviewed original research, review articles, case reports, and editorials. In order to examine the gender distribution of authorship over time, the authors selected four 3-year periods: 1990-1992, 1999-2001, 2008-2010, and 2015-2017. Their goal was to analyze changes in the percentage of women who published as first-, last- and corresponding authors over a 28-year time-span, and the results were not surprising. For the entire study period, women were significantly less likely to hold the position of first author (22.4%), last author (10.3%) and corresponding author (14.6%), than men. The paucity of women serving as senior authors is striking but has a logical explanation. Last authors are typically specialists holding the highest academic rank, are established researchers and experienced mentors. It is also a well-known fact that women physicians are better represented at mid-level career than in the higher academic ranks.2Blumenthal D.M. Olenski A.R. Yeh R.W. et al.Sex differences in faculty rank among academic cardiologists in the United States.Circulation. 2017; 135: 506-517Crossref PubMed Scopus (86) Google Scholar In the present study, the percentage of publications by women as first authors increased substantially over time (from 9.6% in 1990-92 to 26.2% in 2015-17), while there was a significantly smaller change when women served as project mentors and senior authors (7.0% in 1990-92 to 11.8% in 2015-17). This echoes the reality found in other medical specialties such as surgery, cardiology, and emergency medicine (to name only a few), and suggests that women are severely under-represented among physicians within the higher academic ranks.6Mueller C. Wright R. Girod S. The publication gender gap in US academic surgery.BMC Surg. 2017; 17: 16Crossref PubMed Scopus (84) Google Scholar, 7Asghar M. Usman M.S. Aibani R. et al.Sex differences in authorship of academic cardiology literature over the last 2 decades.J Am Coll Cardiol. 2018; 72: 681-685Crossref PubMed Scopus (31) Google Scholar, 8Zhuge Y. Kaufman J. Simeone D. et al.Is there still a glass ceiling for women in academic surgery?.Ann Surg. 2011; 253: 637-643Crossref PubMed Scopus (323) Google Scholar When examining the temporal changes in female authorship over the course of 28 years, Pagel et al made an interesting observation concerning all publication types. There was a notable increase in the number of publications by female authors from 1990-92 (12.1%) to 2015-17 (22.9%). This is a positive finding that correlates with the conclusions from other studies examining female authorship in medical journals with a high impact factor (Table 1). A closer look at this temporal dynamic, however, reveals that after the initial increase in women's publications from 1990-92 to 2008-10, there is a plateau among almost all publication types. As a result, the number of female authored publications in the Journal has remained fairly flat for the last decade. Jagsi et al also noted a similar loss of momentum over time, with the sharpest gains occurring in the female-dominated specialties of pediatrics and obstetrics & gynecology despite a plateau effect (Table 1).1Jagsi R. Guancial E.A. Worobey C.C. et al.The “gender gap” in authorship of academic medical literature—A 35-year perspective.N Engl J Med. 2006; 355: 281-287Crossref PubMed Scopus (607) Google Scholar The specific reasons behind this lack of any further increase in female authorship over the last 10 years are largely unknown, however, Filardo et al have demonstrated a similar trend in publications by female authors in 6 high-impact journals after the year 2010.9Filardo G. da Graca B.D. Sass D.M. et al.Trends and comparison of female first authorship in high impact medical journals: Observational study (1994-2014).BMJ. 2016; 352: i847Crossref PubMed Scopus (286) Google Scholar Their group even showed a trend toward decreased publications by female authors after 2010 in the British Journal of Medicine, The Lancet and the New England Journal of Medicine, findings similar to those in the present study. They noted that from 1994-2014 female first authorship increased from 27% to 37%, while first authorship eventually plateaued, showing no meaningful gains between 2009-2014. In a study of 6 peer-reviewed journals from the United Kingdom from 1970-2004, female representation increased on average from 10.5% to 36.5% and 12.3% to 16.5% for first- and senior authors, respectively, though there were significant differences based on specialty.10Sidhu R. Rajashekhar P. Lavin V.L. et al.The gender imbalance in academic medicine: A study of female authorship in the United Kingdom.J R Soc Med. 2009; 102: 337-342Crossref PubMed Scopus (134) Google ScholarTable 1Studies evaluating the percentage of female first authors in various peer-review journals over time. The last two columns represent the percentages at the beginning and end of each study period, respectivelyAuthor/YearStudy PeriodJournal% Female 1st Authors (Start)% Female 1st Authors (End)Filardo G et al9Filardo G. da Graca B.D. Sass D.M. et al.Trends and comparison of female first authorship in high impact medical journals: Observational study (1994-2014).BMJ. 2016; 352: i847Crossref PubMed Scopus (286) Google Scholar20161994-2014Annals of Internal Medicine26%51%Archives of Internal Medicine33%42%British Medical Journal35%36%Journal of American Medical Association33%46%The Lancet27%31%New England Journal of Medicine28%25%Asghar M et al7Asghar M. Usman M.S. Aibani R. et al.Sex differences in authorship of academic cardiology literature over the last 2 decades.J Am Coll Cardiol. 2018; 72: 681-685Crossref PubMed Scopus (31) Google Scholar20181996-2016American Journal of Cardiology10.5%21%Journal of American College of Cardiology11%16.1%British Medical Journal Heart13.7%27.8%European Heart Journal13.1%20.3%Clinical Cardiology6.5%21%Circulation11.5%23.8%Jagsi R et al1Jagsi R. Guancial E.A. Worobey C.C. et al.The “gender gap” in authorship of academic medical literature—A 35-year perspective.N Engl J Med. 2006; 355: 281-287Crossref PubMed Scopus (607) Google Scholar20061970-2004New England Journal of Medicine4.3%14.1%Journal of American Medical Association5.7%26.5%Annals of Internal Medicine4.7%31.5%Annals of Surgery2.3%16.7%Obstetrics & Gynecology6.7%40.7%Journal of Pediatrics15.0%38.9%Miller J et al11Miller J. Chuba E. Deiner S. et al.Trends in authorship in anesthesiology journals.Anesth Analg. 2018; (E-pub ahead of print)https://doi.org/10.1213/ANE.0000000000003949Crossref Scopus (59) Google Scholar20182002-2017Anesthesiology20.1%31.6%Anesthesia & Analgesia20.8%29.7%Pagel PS et al5Pagel PS, Freed JK, Lien CA. Gender differences in authorship in the Journal of Cardiothoracic and Vascular Anesthesia: A 28-year analysis of publications originating from the United States, 1990-2017. J Cardiothorac Vasc Anesth (current issue).Google Scholar20191990-2017Journal of Cardiothoracic and Vascular Anesthesia9.6%26.2% Open table in a new tab A recent publication examining trends in authorship over 4 time periods (2002, 2007, 2012, 2017) in two high-impact anesthesiology journals, Anesthesiology and Anesthesia & Analgesia, found that women saw overall increases in first- and senior-authorship, and editorial board membership of 10%, 9%, and 6%, respectively.11Miller J. Chuba E. Deiner S. et al.Trends in authorship in anesthesiology journals.Anesth Analg. 2018; (E-pub ahead of print)https://doi.org/10.1213/ANE.0000000000003949Crossref Scopus (59) Google Scholar Though these figures are encouraging, they are far from earth-shattering. The greatest female representation was in the subspecialties of neuroanesthesia, obstetric anesthesia, pain management, and pediatric anesthesia. Cardiac anesthesia had the lowest female first author representation in the clinical subspecialties, and the second lowest in senior authorship after critical care. One would like to believe that the review process is fair and unbiased, but this notion has been put into question by some.12Khan K. Is open peer review the fairest system?.No. Br Med J. 2010; 341: c6425Crossref PubMed Scopus (37) Google Scholar, 13Groves T. Is open peer review the fairest system?.Yes. Br Med J. 2010; 341: c6424Crossref PubMed Scopus (41) Google Scholar In a survey-based study of biomedical academics from high-ranking universities throughout the world on the subject of peer review systems of medical journals, less than half of respondents felt that the peer review system was fair, scientific, or transparent, with a majority favoring a double-blind peer review system.14Ho R.C. Mak K. Tao R. et al.Views on the peer review system of biomedical journals: An online survey of academics from high-ranking universities.BMC Med Res Methodol. 2013; 13: 74Crossref PubMed Scopus (47) Google Scholar Female gender was one factor that was independently and inversely associated with agreement that biomedical journal peer review is fair. Concerns about single blind review are that it may be associated with biases that include gender, nationality, language of authors, and prestige of the author's institution.15Snodgrass R. Single- versus double-blind reviewing: An analysis of the literature.SIGMOD Record. 2006; 35: 8-21Crossref Scopus (77) Google Scholar A study examining the impact of single blind review on the acceptance of manuscripts from “reputed scholars” compared to “newcomers” in computer science actually found that the latter group was at a disadvantage.16Seeber M. Bacchelli A. Does single blind peer review hinder newcomers?.Scientometrics. 2017; 113: 567-585Google Scholar It has been suggested that blinding of both authors and referees (double-blind review) might mitigate some of the bias problems that may occur in publication, though opinions still diverge on this matter.17West J.D. Jacquet J. King M.M. et al.The role of gender in scholarly authorship.PLoS One. 2013; 8: e66212Crossref PubMed Scopus (433) Google Scholar, 18Rexrode K.M. The gender gap in first authorship of research papers.BMJ. 2016; 352: i1130Crossref PubMed Scopus (18) Google Scholar Coming back to the subject of literature and gender disclosure, Catherine Nichols revealed a striking reality when, in 2015, she received 8 times more publishing requests when she used the male pseudonym George Leyer.19Nichols C. Homme de Plume: What I learned sending my novel out under a male name. https://jezebel.com/homme-de-plume-what-i-learned-sending-my-novel-out-und-1720637627? (accessed December 30, 2018)Google Scholar And this was just 3 years ago! Francine Prose posed the question “Are women writers really inferior?” in an often-referenced essay where she challenges readers to distinguish between male and female “sounding” writing.20Prose F. Scent of a woman's ink. Are women writers really inferior?. Harper's Magazine, June 1998: 61-70Google Scholar And of course, Virginia Wolff famously stated in A Room of One's Own, “I would venture to guess that Anon, who wrote so many poems without signing them, was often a woman.” The Journal of Cardiothoracic and Vascular Anesthesia employs a double-blind peer review process, eliminating the possibility of gender bias in manuscript acceptance. On the other hand, Anesthesiology and Anesthesia & Analgesia are single-blinded. In order to know whether the blinding process has had any impact on cardiothoracic anesthesia publications by women, one would need to conduct an in-depth review of specialty-specific publications between the journals, a daunting task. Noteworthy is the fact that the impact factors of Anesthesiology and Anesthesia & Analgesia are higher than the Journal of Cardiothoracic and Vascular Anesthesia, which might affect an author's choice of journal for submission. It is important to keep in mind, however, that the former 2 have had the advantage of being the designated journals for the American Society of Anesthesiologists (ASA) and the Society of Cardiovascular Anesthesiologists (SCA), respectively, although the Journal of Cardiothoracic and Vascular Anesthesia has very recently been added as an option for SCA members. With all this said, it is clear that the gender disparities in authorship are multifactorial, with numerous and complex elements implicated. The list is long, and may include: inadequate/disparate research funding; institutional and leadership failures to support and promote women; competitive disadvantage; gender bias (conscious and unconscious); greater confidence gap relative to men; full-time versus part time status and productivity; greater rejection of manuscripts; lack of mentoring; impact of traditional gender roles; choice of work hours and personal choices regarding work-life balance; uneven parenting responsibilities; family planning; different peaks in productivity compared to men; bias against women in the review process; and career duration.21Allen I. Women doctors and their careers: What now?.BMJ. 2005; 331: 569-572Crossref PubMed Scopus (105) Google Scholar, 22Lundine J. Bourgeault I.L. Clark J. et al.The gendered system of academic publishing (Comment).Lancet. 2018; 391: 1754-1756Abstract Full Text Full Text PDF PubMed Scopus (92) Google Scholar One must also not ignore the fact that the gender composition and hierarchy of academic departments, along with what has been described as a “leaking pipeline” are rate limiting steps in the process.23Arnett D. Plugging the leaking pipeline—Why men have a stake in the recruitment and retention of women in cardiovascular medicine and research.Circ Cardiovasc Qual Outcomes. 2015; 8: S63-S64Crossref PubMed Scopus (10) Google Scholar While some specialties such as surgery have seen a steady increase in the percentage of women entering their training programs, anesthesiology has remained stagnant with just over one-third female representation.24Accreditation Council for Graduate Medical Education. Data Resource Book. Available at: http://www.acgme.org/About-Us/Publications-and-Resources/Graduate-Medical-Education-Data-Resource-Book. Accessed December 30, 2018.Google Scholar Around one quarter to one third of cardiothoracic anesthesia fellows have been women over the last decade. This number correlates closely with the percentage of women practicing this specialty in departments with accredited fellowships, as noted by Pagel et al. Thus, data shows us that the percentage of women entering the specialty of cardiothoracic anesthesia, the percentage of women practicing their specialty in academic institutions, and ultimately the percentage of women publishing in the field of cardiothoracic anesthesia have followed similar trends in the last 10 years. These figures are encouraging but bring us back to the notion that greater recruitment of women into anesthesiology (and ultimately cardiothoracic sub-specialization) will be necessary before we can ever hope to approach parity. Whether we are talking about science or the arts, literature or medicine, one thing is inherently clear. Women over the years have been marginalized as writers, but the causes are multiple and cannot be solely attributed to bias and gender discrimination. The plateau effect seen in this study is pervasive among specialties and in need of further investigation. In the meantime, there are ample opportunities to improve the engagement of women anesthesiologists in clinical research, provide solid academic support and mentorship for grant application, and acknowledge their contributions as writers. Until we have objectively identified the obstacles faced by women in academic medicine and acted on them, women will continue to hit a wall when it comes to journal authorship. Gender Differences in Authorship in the Journal of Cardiothoracic and Vascular Anesthesia: A 28-Year Analysis of Publications Originating From the United States, 1990-2017Journal of Cardiothoracic and Vascular AnesthesiaVol. 33Issue 3PreviewGender-based differences in scholarship among cardiothoracic anesthesiologists have not been studied. The authors examined the gender distribution of authorship of original research articles, case reports, review articles, and editorials in the Journal of Cardiothoracic and Vascular Anesthesia (JCVA) originating from the United States during four 3-year intervals to determine temporal changes in productivity of women in cardiothoracic anesthesiology. The authors tested the hypothesis that scholarly output of women has increased progressively in JCVA over time concomitant with greater participation in first, last, and corresponding author roles. Full-Text PDF